FUTURE   POLICY  IN   DEALING    WITH  DIS- 
ABLED CIVILIANS;  SOME  CONCLU- 
SIONS FROM  EXPERIENCE. 

By  DOUGLAS  C.  McMURTRIE, 

NEW  YORK. 

DIRECTOR,  RED  CROSS  INSTITUTE  FOR  CRIPPLED  AND  DISABLED  MEN, 
PRESIDENT,    FEDERATION   OF  ASSOCIATIONS   FOR  CRIPPLES. 

The  rehabilitation  for  self-support  of  disabled  sol- 
diers and  sailors  has  attracted  wide  public  interest. 
As  we  now  enter  upon  the  reconstruction  period 
there  arises  the  question  as  to  how  far  the  policies 
developed  in  dealing  with  military  cripples  can  be 
carried  over  for  the  benefit  of  disabled  civilians. 
Some  results  have  already  been  accomplished  in  the 
reeducation  of  industrial  cripples.  What  conclu- 
sions helpful  to  the  formation  of  future  state  or 
national  policy  have  been  drawn? 

The  first  conclusion  from  experience  is  that  re- 
habilitation of  the  disabled  does  not  consist  solely 
in  vocational  education.  It  is  as  largely  a  piece 
of  social  work  as  it  is  educational.  The  chief  prob- 
lem of  any  individual  disabled  man  is  a  character 
problem.  The  chief  necessity  is  to  inspire  his  ambi- 
tion, to  overcome  the  tendency  to  inertia,  combat 
the  psychological  conditions  which  inevitably  de- 
velop with  a  permanent  injury,  and  to  inspire  per- 

Copyritfht    William  Wood  ft  Company. 


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severance  to  continue  the  effort  at  rehabilitation 
when  once  begun. 

Successfully  to  deal  with  the  disabled  men  re- 
quires a  special  understanding  of  their  difficulties 
and  extraordinary  patience  on  the  part  of  direc-( 
tors,  advisers,  teachers,  or  social  workers.  The 
average  disabled  man,  and  particularly  the  civilian 
cripple,  who  enters  on  a  course  of  training,  is  likely 
to  abandon  it  in  discouragement  at  the  end  of  the 
first  week.  The  average  teacher  who  deals  with 
him  is  likely  to  become  disgusted  before  that  time 
and  be  perfectly  willing  to  let  him  abandon  the 
course  in  the  sure  belief  that  the  man  is  not  worth 
bothering  about.  Yet  those  who  have  dealt  with 
cripples  understand  that  this  is  not  the  case,  and 
that  with  the  rule  of  "try,  try  again"  success  can 
be  attained  in  the  great  majority  of  instances. 

Although  I  heartily  believe  in  the  restoration  of 
a  disabled  man  to  a  place  in  the  community  as  a  nor- 
mal being,  rather  than  committing  him  to  a  special 
colony  for  cripples,  I  am  convinced  that  the  most 
effective  agency  of  rehabilitation  is  a  special  school 
for  the  physically  handicapped.  In  such  a  school 
every  facility  is  designed  for  disabled  pupils  and 
all  members  of  the  staff  are  originally  picked  for 
aptitude  in  dealing  with  cripples,  and  their  cumu- 
lative experience  makes  them  more  skilled  in  doing 
so.  All  the  members  of  the  staff  of  the  Red  Cross 
Institute  testify  that  difficulties  they  considered 
insuperable  in  the  first  twenty  men  dealt  with  are 
now  minimized  by  experience. 

A  special  school  for  the  disabled  can  have  its 
own  social  service  staff,  an  attending  physician  to 
keep  watch  on  the  condition  of  the  men  from  the 
medical  or  surgical  viewpoint,  and  a  staff  of  teach- 
ers fully  familiar  with  the  special  requirements  of 
the  work. 

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Foreign  experience  in  rehabilitation  seems  to 
point  most  clearly  to  the  need  of  special  schools. 
Practically  all  the  schools  of  reeducation  in  France 
have  been  organized  for  war  cripples.  In  Great 
Britain,  where  the  existing  facilities  of  technical 
institutes  have  been  largely  availed  of,  it  has  been 
found  in  experience  necessary  to  start  special  classes 
or  sections  for  the  disabled,  as  the  men  did  not  mix 
successfully  with  the  regular  pupils.  Even  in  Can- 
ada, with  the  exception  of  the  interesting  placement 
in  apprenticeship  which  has  been  done,  the  most 
successful  reeducation  has  been  in  schools  given 
over  to  become  special  institutions  for  disabled  sol- 
diers. 

These  considerations  lead  me  to  believe  that  mis- 
cellaneous introduction  of  disabled  persons  into 
a  general  system  of  vocational  education  would  be 
unwise,  but  that  the  establishment  of  special  insti- 
tutions for  the  disabled  would  be  most  highly  de- 
sirable. 

The  mere  offer  of  vocational  rehabilitation  ad- 
vantages does  not  by  any  means  solve  the  problem 
of  the  idle  disabled  men,  and  it  cannot  safely  be 
assumed  that  any  considerable  number  of  injured 
men  in  the  United  States  will  take  advantage  of 
rehabilitation  opportunity,  unless  there  is  very  radi- 
cal readjustment  of  present  state  legislative  provi- 
sions. 

Our  experience  at  the  Red  Cross  Institute  for 
Crippled  and  Disabled  Men  in  New  York  very 
clearly  illustrates  this  point.  For  over  a  year  this 
school  of  re-education  has  been  in  operation.  It 
offers  a  reasonable  variety  of  subjects  of  instruc- 
tion, six  in  all :  mechanical  drafting,  moving-picture 
operating,  oxyacetylene  welding,  printing,  the  mak- 
ing of  artificial  limbs,  and  jewelry  work.    All  its 

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advantages  are  free,  yet  it  has  at  the  present  time 
less  than  forty  pupils. 

There  are  in  New  York  City,  however,  according 
to  statistics,  thousands  upon  thousands  of  cripples 
who  would  profit  by  reeducation.  What  is  the  rea- 
son they  do  not  take  advantage  of  the  opportu- 
nity? 

The  answer  is  found  in  the  other  influences  upon 
the  disabled  man.  The  most  potent  of  these  is  the 
theory  and  practice  of  workmen's  compensation. 
Practically  every  compensation  case  that  has  ever 
come  to  the  Red  Cross  Institute  has  come  upon 
the  day  compensation  expired.  For  one  year,  for 
two  years,  or  for  four  years,  the  man  had  existed 
in  idleness,  drawing  compensation,  and  when  this 
support  was  cut  off  he  cast  about  and  became  inter- 
ested in  rehabilitation.  When  we  come  to  examine 
the  compensation  provisions  of  the  various  States 
we  find  that  they  encourage  idleness,  in  that  the 
compensation  payments  are  adversely  affected  by 
any  improvement  in  earning  capacity. 

At  a  recent  conference  there  was  discussion  of 
who  should  meet  the  cost  of  rehabilitating  the 
disabled  men.  As  far  as  the  industrial  cripple 
is  concerned,  so  soon  as  the  movement  and  its 
philosophy  shall  have  gained  some  headway  there 
should  be  no  cost  whatever.  Merely  by  a  reappor- 
tionment of  funds  already  provided,  effected  through 
an  understanding  of  the  possibilities  of  rehabilita- 
tion, there  will  be  a  net  cash  saving  rather  than 
increase  in  expenditure.  I  can  more  clearly  illus- 
trate the  possibility  of  this  by  statement  of  a 
typical  case  than  by  much  theoretical  elaboration. 
A  worker  in  Massachusetts  was  injured  by  a  fall 
while  working  inside  a  submarine,  and  his  hand 
became  permanently  crippled.    In  due  course  his 


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compensation  rate  was  determined,  and  he  was  re- 
ferred to  the  insurance  carrier  to  be  paid  ten  dollars 
a  week  for  a  long  period,  with  a  maximum  total  pay- 
ment of  four  thousand  dollars.  Since  the  disability 
was  manifestly  permanent  the  insurance  company 
wrote  the  case  off  their  books  as  a  four  thousand 
dollar  loss  and  transferred  that  amount  to  reserve 
to  cover  the  weekly  payments.  After  the  compen- 
sation had  been  paid  for  nearly  a  year  a  new  official 
of  the  insurance  company  began  looking  over  the 
list  of  men  to  whom  the  company  was  paying  com- 
pensation. His  attention  was  directed  to  the  man 
in  question,  and  the  latter  was  requested  to  call  at 
the  office  of  the  company.  The  case  was,  like  many 
thousands  of  others,  susceptible  of  rehabilitation  for 
self-support,  so  the  insurance  company  official  put 
a  proposition  to  the  man  in  very  frank  terms.  "I 
believe  that  you  can  be  trained  to  earn  a  good 
living.  I  want  you  to  understand  very  clearly,  how- 
ever, that  this  proposal  is  to  the  financial  advantage 
of  the  company,  but  I  also  believe  it  is  to  your  ad- 
vantage as  well.  A  total  income  of  ten  dollars  a 
week  is  not  very  attractive  to  you,  and  you  would 
probably  rather  return  to  work  at  a  good  wage  than 
remain  idle.  If  you  will  consent,  the  company  will 
send  you  to  a  school  of  reeducation  and  see  if  we 
cannot  get  you  back  on  your  feet  in  good  shape." 

The  injured  man  consented  to  the  proposal,  and 
the  company  sent  him  to  the  Red  Cross  Institute 
in  New  York.  They  began  to  pay  him  not  ten 
dollars  a  week  as  required  by  law,  but  forty  dollars 
a  week,  twenty  to  him  in  New  York  and  twenty  to 
his  wife  at  home.  The  company  also  paid  liberally 
his  traveling  expenses  in  both  directions.  In  the 
period  of  eight  weeks  he  was  reeducated  in  oxy- 
acetylene  cutting  and  welding  and  returned  home. 


He  is  now  making  not  only  a  satisfactory  wage,  but 
twice  as  much  as  he  had  ever  earned  before  the 
accident  took  place. 

In  the  whole  transaction  every  party  at  interest 
was  benefited.  The  man  was  advantaged  in  that  his 
general  living  standard  was  distinctly  raised,  and 
the  necessity  of  working  for  his  living  could  not  be 
considered  as  a  hardship.  The  company  paid  less 
than  five  hundred  dollars  for  his  rehabilitation,  and 
this  expense,  in  conjunction  with  the  five  hundred 
dollars  already  paid  in  weekly  compensation  during 
the  first  year  of  idleness,  made  a  total  for  the  case 
of  one  thousand  dollars.  They  were  thus  enabled 
to  charge  three  thousand  dollars  of  profit  to  the 
account  of  profit  and  loss.  Had  the  course  of  train- 
ing been  earlier  begun,  there  would  have  been  saved 
five  hundred  dollars  more.  The  community  was 
infinitely  the  gainer  in  that  the  man,  formerly  an 
unproductive  consumer,  became  a  useful  producer 
instead.  The  community  further  gained  in  the  elim- 
ination of  the  disabled  man  from  the  category  of  a 
prospective  dependent,  because  while  compensation 
might  have  taken  care  of  him  in  a  very  insufficient 
way  during  the  period  the  payments  ran,  there 
would  have  come  a  time  when  compensation  ceased, 
and  then  he  would  have  been  in  a  desperate  economic 
status  indeed — confirmed  in  habits  of  idleness,  un- 
trained for  skilled  work,  and  without  any  source 
of  support. 

It  is  perfectly  clear  that  if  State  compensation 
authorities  will  alter  their  practice  so  as  to  encour- 
age rehabilitation  rather  than  discourage  it,  if  cas- 
ualty insurance  companies  will  see  the  path  of 
true  economy  (and  they  are  coming  to  this  at  the 
present  time),  there  will  be  no  cost  in  the  rehabili- 
tation of  the  industrial  cripple  but  rather  a  great 


6 


economic  and  social  saving.  The  case  just  cited 
throws  interesting  light  on  the  question  raised  as 
to  whether  future  legislation  should  embrace  in  its 
scope  accident  cripples  not  under  protection  of 
workmen's  compensation  laws,  congenital  cases,  and 
disease  cripples.  If  any  legislation  is  to  be  passed 
these  classes  should  most  emphatically  be  included 
because  they  constitute  the  cripples  who  are  most 
in  need  of  assistance.  As  has  been  shown,  with 
developments  which  can  confidently  be  expected 
within  the  next  couple  of  years,  the  industrial  crip- 
ple will  not  be  in  much  need  of  financial  assistance. 
It  is  the  other  cripples  who  contribute  most  largely 
to  dependency  and  who  involve  the  greatest  com- 
munity expense.  Their  restoration  is  desirable  in 
the  extreme,  because  the  elimination  of  dependency 
due  to  physical  handicap  will  lift  a  colossal  burden 
from  the  agencies  of  philanthropic  relief. 

It  has  been  already  stated  that  rehabilitation  is 
intimately  related  to  workmen's  compensation.  So 
far  as  the  industrial  cripple  is  concerned  the  ad- 
ministration of  rehabilitation  should  be  coincident 
with  that  of  compensation.  It  has  not  as  yet  been 
possible  conservatively  to  draw  definite  conclusions 
regarding  the  exact  provisions  of  compensation  laws 
which  should  be  altered.  It  seems  clear,  however, 
that  one  suggestion  can  come  from  the  experience 
of  all  the  belligerent  nations  in  providing  for  the 
pensions  of  disabled  soldiers.  It  has  been  evident 
from  the  first  efforts  at  reeducation  that  pension 
must  be  paid  for  physical  injury  only  and  not  be 
prejudiced  by  increase  of  earning  capacity  and  sub- 
sequent restoration  to  self-support.  Unless  this 
provision  is  made  it  is  almost  impossible  to  per- 
suade men  to  undertake  re-education.  A  man  does 
not  like  to  lose  one  definite  advantage,  even  though 


7 


there  is  a  greater  advantage  in  store.  All  the  mili- 
tary pensions,  therefore,  are  fixed,  and  a  man  may 
earn  twice  as  much  after  his  injury  as  before,  and 
yet  his  pension  will  be  paid  to  him  just  the  same. 
On  the  other  hand,  we  have  learned  that  the  scale 
of  pensions  is  of  comparatively  little  importance  if 
adequate  rehabilitation  advantages  are  offered.  In 
fact,  a  fairly  low  pension  scale  may  be  a  means  of 
character  building  and  encouragement,  whereas  an 
extremely  high  pension  scale  may  tend  to  demorali- 
zation and  prove  an  encouragement  to  idleness. 

It  is  possible,  for  instance,  that  in  the  field  of 
workmen's  compensation  there  may  be  a  small  statu- 
tory award  for  specific  injury,  and  then  be  extended 
in  addition  opportunity  of  reeducation  at  the  ex- 
pense of  the  State  fund  or  insurance  carrier.  If 
an  earnest  attempt  at  rehabilitation  is  made  by 
the  man,  and  for  one  reason  or  another  he  fails, 
there  might  then  be  a  further  discretionary  award 
by  the  State  compensation  authority  making  the 
total  payment  as  great  or  preferably  greater  than 
called  for  by  the  present  scale.  At  any  rate,  the 
rehabilitation  and  compensation  of  industrial  crip- 
ples are  so  intimately  related  as  to  be  almost  impos- 
sible of  administrative  division. 

In  rehabilitation  of  civilian  cripples  what  are  the 
financial  circumstances  involved?  It  is  my  belief 
that  the  cost  of  rehabilitation  will  average  between 
two  hundred  and  three  hundred  dollars  per  case,  but 
this  is,  of  course,  highly  economical,  because  when 
a  man  is  rehabilitated  his  economic  problem  is  solved 
for  good  and  he  is  no  longer  a  charge  in  any  sense 
of  the  word. 

The  expense  of  rehabilitation  will  be  apportioned 
about  as  follows: 

« 


Per  cent. 

Salaries  of  administrative  and  teaching  staff .  .  20 

Maintenance  of  pupils  during  training   50 

Rent,  or  depreciation  and  interest  on  capital 

investment  in  building   1° 

Depreciation  and  interest  on  equipment   10 

Supplies  and  material   10 

You  will  note  that  maintenance  is  the  large  item. 
If  you  take  the  average  cripple  met  on  the  streets 
and  offer  him  the  finest  course  of  reeducation  in 
the  world,  it  is  unlikely  he  will  be  able  to  take  advan- 
tage of  the  opportunity.   Though  he  is  earning  seven 
dollars  a  week,  and  there  is  prospect  of  increasing 
his  income  to  thirty  dollars  weekly,  it  will  be  im- 
possible for  him  to  take  the  course  offered,  because 
he  will  starve  meanwhile.   This  was  one  of  the  first 
lessons  learned  in  starting  out  to  rehabilitate  dis- 
abled civilians.    There  is  necessary  for  the  average 
case  some  form  of  living  allowance,  and  if  the  same 
governmental  principle  is  to  be  applied  to  the  crip- 
pled civilian  as  is  now  applied  to  the  disabled  sol- 
dier, this  is  properly  a  charge  upon  the  rehabilita- 
tion organization.    For  the  industrial  cripple,  of 
course,  this  maintenance  may  come  out  of  compen- 
sation reserves  if  intelligent  adjustment  of  practice 
and  legislation  is  made,  but  for  the  general  accident, 
disease,  or  congenital  cripple,  no  such  source  of 
support  is  available.    Any  provision  of  rehabilita- 
tion would  be,  in  the  mind  of  the  public,  a  failure 
unless  maintenance  were  provided  for. 

In  the  table  iust  presented  there  has  not  been 
taken  into  account  the  medical,  social  service,  and 
follow-up  attention  which  should  likewise  be  encour- 
aged. 

Statistics  show  the  number  of  disabled  persons 
to  be  very  great.   Of  course,  a  very  large  proportion 

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of  these  men,  particularly  those  with  any  character 
or  initiative,  readjust  themselves  industrially  and 
get  back  in  the  work  of  the  world  in  such  a  way  that 
their  employers  hardly  think  of  them  as  cripples. 
A  large  number  can  satisfactorily  be  put  back  into 
employment  through  provision  of  special  and  ex- 
pert placement  facilities.  An  essential  link  in  the 
rehabilitation  program  is  the  provision  of  special 
placement  bureaus  for  the  disabled.  The  Red  Cross 
Institute  in  New  York  has  operated  for  the  past 
year  such  a  bureau,  and  has  found  that  many  men 
need  only  vocational  guidance  and  intelligent  search 
for  a  suilable  job  in  order  to  have  their  problem 
solved.  There  has  been  already  delegated  to  the 
United  States  Employment  Service  of  the  Depart- 
ment of  Labor  a  vast  placement  enterprise.  This 
service  should  be  encouraged  to  develop  in  every 
large  center  of  population  a  special  bureau  for  the 
physically  handicapped.  Such  placement  work  can- 
not satisfactorily  be  done  through  the  ordinary 
public  employment  office,  but  when  done  carefully 
and  thoroughly  is  certainly  a  public  economy. 


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«... 

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